Venous DisordersDiagnosis and Treatment

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1st Edition 1981Prof. H. Fischer, TuebingenDr. H.G. Füllemann, BasleProf. UV. Brunner, ZurichProf. H. Partsch, ViennaDr. R. Stemmer, StrasbourgProf. L.K. Widmer, Basle

2nd Edition 1994Additional authors:Dr. R. Fischer, Surgery, St. GallenProf. K. Jäger, BasleDr. A. Oesch, BerneProf. J. Weber, Hamburg

3rd Edition 2001Revised by:Prof. H. Partsch, ViennaProf. K. Jäger, BasleAdditional authors:Dr. A. Frullini, FlorenceDr. R. Weiss, BaltimoreDr. M. Schadeck, Paris

4th Edition 2009Additional authors:Prof. E. Rabe, BonneDr. W. Blättler, BerneDr. T. Willenberg, Berne

5th Edition 2012

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Contents

Foreword 4

Epidemiology 5

Classification 5

Diagnosis 6

Symptoms 6

Clinical findings relating to chronic venous disorders 7Superficial veins – varicose veins 7Saphenous varicosis 7Reticular varicosis 7Spider veins 7Venous oedema 8Joint changes 8Skin changes 9

Clinical findings relating to acute venous disorders 10Bleeding varicose veins 10Phlebitis 10Deep vein thrombosis (DVT) 11

Examinations using technical equipment 12CW Doppler 12

Duplex sonography 13Principle 13When should duplex sonography be used for further clarification? 13

Evaluation of the venous pump function 14Principle 14Method 14Pump 14

Alternative imaging techniques 15

Treatment of venous disorders 16Compression therapy 16Specific treatment of venous disorders 17

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Foreword

Acute and chronic venous disorders are among the most common ailments affecting the population. Due to the interdisciplinary nature of these conditions, patients are treated by numerous specialist disciplines. These primarily include phlebology, angiology, dermatology, surgery, internal medicine and general medi -cine. This brochure mainly focuses on the latter discipline and is intended to provideinterested parties with succinct, practical information on current developments inphlebology. Since the 1st edition of this brochure in 1981, phlebology has under gonenumerous changes, particularly with regards to the treatment of varicose veins. Theefficacy of sclerotherapy has substantially improved thanks to the introduction of foaming sclerosing agents. Endovenous techniques such as endovenous laser therapyhave also come to the fore in the treatment of saphenous varicose veins. With regardto Deep Vein Thrombosis, low molecular weight heparin is administered as outpatient therapy. Additionally, innovation in design and yarns used in compressiontherapy garments have increased patient compliance and wearing comfort. Peoplewithout serious vascular symptoms are comfortable wearing these more fashionablegarments daily to keep their legs healthy. The substantial medical efficacy of thesestockings has also been confirmed in various studies resulting in more physiciansprescribing graduated compression stockings.

Dr. Helmut Schepers, MScHead of Corporate Medical RelationsSIGVARIS Management AG

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Classification

The CEAP Classification was introduced in 1996 in an attempt to maintain a systemthat would allow the differentiated classification of venous disorders. Since then, this classification system has consolidated its position in the relevant literature and has been used extensively in the interim. It is used in particular within the scope of scientific publications. Every letter in the CEAP classification system stands for a venous disorder component:

C = Clinic: clinical signs (score of 0–6), a = asymptomatic, s = symptomaticE = Etiology: etiological classification according to congenital,

primary and secondaryA = Anatomy: affected segments of veins, superficial, deep, perforating veinsP = Pathophysiology: pathophysiological dysfunction, return, obstruction,

return and obstruction

Epidemiology

Venous disorders are common. Every third pharmacy customer in France islooking for help regarding leg-relateddisorders. The Bonn Vein Study shows thatapproximately half of the Bonn population experienced some form of leg discomfort in the 4 weeks preceding the survey and 15 % admittedto wearing or having previously worncompression stockings.

Deep vein thrombosis (DVT), the mostsevere acute venous disorder, affects 1–2 % of the population each year. The risk of developing a leg ulcer in your life – the most serious form of chronicvenous disorder – is also 1–2 %. Thanks to early diagnosis and evidence-based medicine treatment, the occurrence of this serious complicationhas greatly declined in recent years.However, the risk factor spectrum forvenous disorders has increased alongsidedemographical changes and improveddiagnostic techniques. It is important to note that an isolated case of vein thrombosis and untreated varicose veinsare associated with a disproportionalincrease of vein-related problems as ageadvances.

Clinic C0–C6 Definition Comments

No sign of venous disorders

Spider veins and Spider veins:reticular varices intradermal venulae < 1 mm.

Reticular varices: subdermal, < 3 mm

Varicose veins Subcutaneous, > 3 mm

Oedema Fluid retention

Skin changes C4a: pigmentation, purpura,eczema

C4b: hypodermitis, lipodermosclerosis, White atrophy

Healed ulcer

Open ulcer

C0

C1

C2C3C4

C5C6

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Symptoms

Branch varicosisVena saphena magna (greater saphenous vein)

insufficiency with resulting branch varicosis inthe median section of the upper leg.

Clinical findings relating to chronic venous disorders

Superficial veins – varicose veinsVaricose veins are the most commonindication of superficial venous disorder.It is important to have a thorough know -ledge of the anatomy of the veins inorder to understand and describe theclinical symptoms of varicose veins.Morphologically, a distinction is madebetween the following types of varicoseveins:

Saphenous varicosisVena saphena magna (greater saphenousvein), Vena saphena parva (small saphenous vein). • Complete saphenous varicosis:

the venous return begins at the 1st valve located in front of the aperture where the saphenous vein enters the deep venous system (cross).

• Incomplete saphenous varicosis: saphenous vein insuffi ciency with sufficient cross and return venous flow from another vessel.

• Branch varicosis (flow over an incompetent lateral branch).

• Perforans varicosis (flow over incompetent perforating veins).

Reticular varicosisWinding subcutaneous veins that do notbelong to the main stem neither to thebranches, < 3 mm in diameter

Spider veinsIntradermal vein ectasia

Diagnosis

Leg pain can be indicative of venous disorder without objective signs of this conditi-on. Vein-induced leg symptoms are typically associated with more or less markedswelling of the legs. Characteristic symptoms include a diffuse, bilateral sensation ofswelling, constriction and unrest, etc. These symptoms are hardly discernible in themorning but are marked in the evening, especially after sitting or standing for prolon-ged periods at work, or following exposure to intense heat. They can be prevented oralleviated by elevating the legs, walking around and wearing compression stockings.Studies have shown that leg pain can have emotional origins with mental syndromeslinked to the patient’s personality.The symptoms of acute thrombosis can be interpreted in terms of a compartmentsyndrome. Pain is localised in the calf and is particularly intense while standing andwalking.In proven chronic venous insufficiency, additional symptoms are found such as localpain due to inflammation, pruritus in presence of stasis eczema, muscle pain duringeffort in case of venous stasis.

Chronic venous disorders reduce the patient’s quality of life. Even without importantvenous or skin changes, the mental and social discomfort caused by venous disordersis already significant. With a leg ulcer, the patient’s integrity is affected. Compressiontherapy provides rapid pain relief, but the return to normal life implies completehealing of the ulcer.

Saphenofemoral junction

Anterioraccessory greatsaphenous vein

Perforators of the femoralchannel (Dodd)

Thigh extension of small saphenous vein

Small saphenous vein

Posterior accessory greatsaphenous vein

Posterior accessorygreat saphenous vein

Great saphenous

vein

Posterior tibial perforators(Cockett)

Vein of Giacomini

Saphenopoplietaljunction

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Saphenous varicosisThe Vena saphena magna (greater saphenousvein) and the resulting branch varicose veins inthe median section of the lower leg. Reticular varicosis

Spider veinsIntradermal vein ectasia.

Anatomy of the principal superficial veins and perforating veins frequently affected by varicosis

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Skin changesSkin changes mainly develop due to damage caused by chronic venous hypertension,i.e. due to the lack of pressure relief in the veins on walking. Skin changes are apparent in the region of the primary varicose veins and especially in areas wherethere are incompetent connections to the deep venous system as well as on the distal lower leg and foot. However, the clinical picture is soon dominated by secondary changes: allergic and pathogenic inflammation in chronic oedema andloss of the barrier function of the skin, microvascular thromboses, local ischaemia, reperfusion and toxic damage caused by iron overload, etc. The pathophysiology can be deduced from the clinical picture: dermo-epidermatitis, hypodermatitis, hyperpigmentation and ulceration. The skin vessels can sometimes be reorganised as a result of repair processes: spider veins on the upper leg, flask-shaped varices inthe retromalleolar and paraplantar regions, loss of capillaries in atrophic areas withgiant capillaries. White atrophy is due to Capillaritis alba and finally a microvascular,thrombotic or inflammation-induced circumscribed ischaemia accompanied by severe, acute pain. The leg ulcer develops spontaneously or as a result of minor, often unnoticed traumas. Many ulcers can be healed by compression therapy whilstothers manifest their own biological profile and persist for years. Genetic predisposition appears to be involved.

Venous oedemaIt is not unusual for legs to be swollen inthe evening. The volume of the lower legcan increase by up to 100 ml after a longworking day or up to 200 ml after a long-haul flight without moving. Oedema thatdoes not disappear spontaneously withina few hours or after a walk is describedas pathological. Bilateral and markedoedema with few symptoms is mostlycaused by the systemic circulation (heart,kidneys, liver). Venous oedema is virtuallyalways associated with symptoms and/orclinical signs such as dilated superficialveins, varicose veins and skin changes.Chronic venous oedema is only partiallyreversible and soon becomes hard, whichis mainly confirmed on palpation. All skinstructures are affected and this is charac-terised by the term lipodermatosclerosis(LDS). LDS can develop into atrophy. Thelower leg then takes on the appearanceof an upside down champagne bottle.(Secondary) lymph oedema may develop,in many cases accompanied by acralthickening of the skin folds, hyperkerato-sis and papillomatosis.

Venous oedema is one of the most commonclinical findings. In this case, it may be due toeither the deep or superficial venous system.

Joint changesJoint changes are an inevitable result of venous insufficiency. The initially pain-induced, functional, restricted mobility of the ankle joint, which is subsequently fixedby capsular shrinkage, is of particular significance. The clinical sequelae manifest inthe form of “phlebological Talipes equinus” with the corresponding adverse effect onwalking. Patients tend to compensate for this restriction by wearing high-heeledshoes. The lesion leads to a vicious circle whereby the pumping function of the calfmuscle is considerably affected.

Advanced bilateral, chronic venous insufficien-cy with marked, bilateral muscle atrophy and

Talipes equinus.

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Clinical findings relating to acute venous disorders

Bleeding varicose veinsRuptured varicose veins are the impressive, albeit harmless complicationof a specific form of varicosis: intracutaneous venous aneurysms with a thin wall may rupture without causingpain as a result of minor traumas, e.g. by rubbing the skin after a long bath. The blood often squirts out as a result of the high pressure, lack of muscle inthe vessel wall and the small aperture.Elevation of the legs and a compressiondressing will solve the acute problem.This type of pearl varices is best cleanedby sclerotherapy with eccentric compression.

Phlebitis (superficial venous thrombosis)Vein inflammation (phlebitis) refers to nosological and clinically different symptomsthat can be easily differentiated. In the case of superficial venous thrombosis, a redthrombus is present in a varicose vein with little inflammation in the vein wall but aconsiderable amount around it. The inflammation of non-varicose, superficial veinsaffects the entire vascular wall and, to much less of an extent, the surrounding area.Furthermore, the thrombus in the lumen is small or missing. Vein thrombosis has atendency for appositional growth, i.e. it grows into the deep venous system, whilstthe phlebitis of a non-varicose vein tends to migrate, occasionally jumping over ontoother sections of veins (migratory phlebitis). In both forms of venous inflammation,deep vein thrombosis and oligosymptomatic pulmonary embolisms are not uncommon. Follow-up ultrasound scans are therefore carried out in both cases. As for venous thrombosis, a rapid improvement in the patient’s condition is generallyobtained by removing the thrombi via stab incision(s) or heat-mediated varicosesurgery.

Bleeding from a pearl varicose vein in the region of the Malleolus latendis.

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Deep vein thrombosis (DVT)Clinical findings in deep vein thrombosis depend on the patient’s condition and theextent of the thrombosis. In patients who are confined to bed, the findings are sosubtle that diagnosis is often made late.

Cyanosis, dilated superficial veins and overheating are typical warning signs. Outpatients quickly present with findings indicative of a compartment syndrome:hardening of the affected area (soles of the feet, calf), tender muscles, reducedballottement, pain on standing and walking as well as on active or passive dorsalextension of the foot. Essential oedema, i.e. a difference of > 3 cm in calf circumference compared to the opposite leg, is only to be anticipated in ascendingthrombosis when the thrombosis has reached the inguinal vein. On the other hand,descending thrombosis quickly and typically leads to severe swelling and not primarilyto calf compartment syndrome.

Ultrasound scan of a longitudinal sectionthrough a thrombosed vein.

Duplex image of an average thrombosed vein,accompanied by the femoral artery in red (noabnormalities recorded).

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Examinations using technical equipment

CW (Continuous Wave) DopplerThis examination is suitable for providinga cursory estimate of vein valve function.The following questions can be answered:

1.Are deep veins permeable? (examination carried out in the supine position)

2.Are the valves in the deep or superficialveins sufficient? (examination carried out standing or seated)

Normal electrical current, breathing-dependent.

Pathological current, not breathing-dependent(e.g. in vein thrombosis).

Normal: Valsalva test: Doppler signal silencedby pressing – no return.

Pathological: Valsalva test: Doppler signal persists on pressing – return.

Duplex sonography

PrincipleDuplex sonography combines the Bmode, duplex (colour) and the Doppler,thus permitting a thorough and, in mostcases, complete examination of the deepand superficial venous systems.

B image:Highlighting vessels and surroundingstructures.Duplex and Doppler:Quantifying the flow; in the colourduplex, haemodynamic information isdirectly transmitted to the morphologicalimage.Advantages of duplex sonography:Greater information content, non-invasive.Disadvantages of duplex sonography:Operator dependency, no overviewimage.

When should duplex sonographybe used for further clarification?Every symptomatic venous disorderrequiring active treatment should beclarified using duplex sonography. Inmost cases, this allows the aetiology,extent and morphology of the venousdisorder to be determined and a firmtreatment concept to be developed.

Cross (Saphena magna – greater saphenous vein – aperture)

Orthograde flow (blue). Return with valve aperture insufficiency duringValsalva press test (red).

Distal section of the upper leg (Saphena magna, longitudinal section)

Normal orthograde flow (blue). Return under Valsalva press test (red).

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Evaluation of the venous pump function

Principle Recording changes in volume andpressure on the distal extremities belowwhen in motion (standing on tiptoe,bending knees, walking).

Method Light reflection rheography, photoplethysmography, elastic strip plethysmography, foot volumetry, air plethysmography or measurement of venous pressure in a vein at the backof the foot.

PumpWith each movement, blood drains fromthe legs and venous pressure is reduced.This mechanism is impaired in cases ofsuperficial or deep venous valueinsufficiency, or when the deep veins areobstructed. Venous pressure remainshigh and there is inadequate draining ofthe venous blood. By compressing thedefective veins (e.g. the truncal veins),the venous pumping function can be returned to normal again. Functionalexaminations are carried out with andwithout a tourniquet to determine thescope for improving venous function,making it possible to predict theanticipated success of a course oftherapy.

No disruption to the venous pump.

Probe application in light reflection rheography.

Venous (pump) insufficiency.

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Alternative imaging techniques

• Phlebography• Phlebo-CT, MRIThese techniques are seldom used byvein specialists in their current clinicalroutine but are mainly employed withinthe scope of scientific examinations.Phlebography was replaced by theintroduction of duplex sonography. Itnevertheless remains an importantdiagnostic tool in special investigationsand, as a gold standard, can provide acomplete and accurate anatomicaloverview of the deep and superficialvenous systems in the leg. Modernimaging techniques such as CT or MRIscans can also be used.

This type of special investigation wouldbe required in pelvic vein obstructions orin the event of complex venous orcombined arterio-venous malformation.

Image portraying incompetent perforatingveins in the median section of the lower leg.

Image of inguinal varicose vein checks after incomplete crossectomy.

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Treatment of venous disorders

Compression therapyLeg bandaging has been carried out forthousands of years, possibly as part of aritual, and was confirmed as a medicinalstrategy in Ancient Greece.Compressing leather boots have beenused for therapeutic purposes since theMiddle Ages, and elastic fabric andrubber stockings since the 19th century.Indications were based on clinicalexperience of efficacy and were muchthe same as they are today: oedema,varicose veins and skin lesions.A wide range of mechanisms of actionwas offered, based on the pathophysio-logical conditions of the time: constric- tion of the veins, improved valve function,reduced volume of blood in the veins and improved pumping action, amongstothers. The reduction of oedema, animprovement in inflammatory skinchanges and the healing of ulcers areclinically feasible on a regular basis. Thesuccessful treatment of such pathologicalstates, which can be determined objectively, coupled with the beneficialeffect on symptoms, quality of life andeven on the prognosis of certain disorders, has been confirmed in clinicalstudies.Bandaging has always been an art. Manymethods for applying bandages werethus developed and enthusiastically

encouraged, but their effects in certainindications were not compared untilrecently. Medical compression stockings(MCS) are becoming increasingly populardue to improved compression levels,reproducible efficacy, ease of use, long-lasting effect and excellent tolerance.Sophisticated textile technology enablesthe industrial pro duction of medicalcompression stockings with graduatedcompression – strong at the ankle anddecreasing going up the leg – in manydifferent models and fashion styles.MCS with 20 – 30 mmHg ankle pressurelevel are the most widely sold compression products, especially inGermany. This compression level represents the optimal treatment formany indications, because of the provenefficacy of MCS ease of use and compliance.A different range of indications has beendefined over the past years: MCS with 15 – 20 mmHg pressure are best for theprevention and treatment of occasionalleg symptoms and oedema. Supportstockings of less than 10 mmHg pressureare just ineffective. On the other hand,MCS with high pressure maybe too firmfor occasional symptoms, and thereforeless accepted by patients.MCS are also effective for the treatmentof leg ulcers. In randomised studies

carried out to date, MCS have proventheir efficacy over bandages in terms ofhealing rate, speed, pain management,ease of use, and many other subjectivepoints. However, some prerequisites arenecessary in order to treat a leg ulcerwith MCS, such as a certain degree ofankle mobility.Systems using two stockings, one overthe other, have proved to be especially effective, not only for leg ulcer management, but also to treat othersevere forms of chronic venous disorders. The under-stocking with 15 mmHg iseasy to don and holds the wound dressings in place. It’s only removed tochange the dressing and to wash the leg.Each morning the second stocking withhigh compression is easily put over theunder-stocking and removed in theevening. In an initial comparative study,the SIGVARIS Ulcer X double stockingsystem proved to be the most effectiveproduct in terms of desired compressionlevel and ease of use.

Treatment of spider veins with a foaming sclerosing agent.Phlebectomy of branch varicose veins.

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Specific treatment of venous disordersVaricose veinsThe indication for the treatment of varicose veins depends on the etiology and causeof the disorder. Non-symptomatic varicose veins that do not present any essential skinchanges in terms of chronic venous insufficiency do not require any special medicaltreatment. This applies to spider veins, for instance.Therapeutic measures are indicated if symptomatic varicosis is present and/or if skinchanges indicative of chronic venous insufficiency develop. In this case, a distinction is made between conservative and invasive-ablative techniques.

Conservative • Prophylaxis: good mobility, elevate the legs • Compression therapy: use of medical compression stockings

Invasive ablative techniques• Standard varicose vein surgery (crossectomy, stripping and phlebectomy)• Thermo-ablative techniques (percutaneous endovenous laser, application of

radiowaves or hot steam)• Sclerotherapy: injection of a liquid or foaming sclerosing agent into the varicose

veins. Indication ranging from spider veins to saphenous varicose veins (in this case,ultrasound-guided sclerotherapy).

ThrombosisThe treatment of acute vein thrombosisof the legs always involves anticoagulation therapy. The latterprevents the thrombosis from advancingand precludes the formation of pulmonary embolisms. A surgical procedure to restore vein function isrecommended when treating ilio-femoralthromboses. With a few exceptions tothe rule, patients are immediately givencompression therapy and are activelyencouraged to walk. Symptoms willquickly regress as a result and the development of chronic venous insufficiency will be prevented in 50% ofcases. Calf stockings with 20 – 30 mmHgankle pressure appear to be sufficient.They can be worn day and night. A 2-year compression therapy programme is planned. Treatment can be stopped if a phlebological follow-upexamination confirms the absence of anyobstructions or return in the deep veins.The wearing of compression stockings isrecommended to prevent recurrence ofthe condition in risk situations.

Thermo-ablation of saphenousvaricose veins using a laser. The vein is destroyed by the heatreleased on pulling back the activated laser probe.

Ligating of the Vena saphena magna (greater saphenous vein)following inguinal crossectomy.Ultrasound-guided sclerotherapy.

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